Molar Pregnancy

A form of gestational trophoblastic disease.

Complete mole (46XX, entirely paternal genetic origin, no fetal tissue, diffuse trophoblastic hyperplasia) carries a higher risk of progression to persistent gestational trophoblastic disease or choriocarcinoma (roughly 15 to 20%) than partial mole (69XXY triploid, fetal tissue present, focal hyperplasia, risk roughly 0.5 to 1%).

Suction curettage (evacuation) is the treatment of choice regardless of uterine size; oxytocics are generally avoided or used cautiously until evacuation is complete
Anti-D prophylaxis for Rh negative women
Serial serum beta-hCG monitoring post-evacuation until three consecutive normal weekly results, then monthly for 6 months for complete mole (shorter follow up for partial mole per local protocol), with registration at a specialist gestational trophoblastic disease center
Effective contraception during follow up to avoid confounding hCG monitoring, barrier methods or combined oral contraceptive once hCG has normalized; intrauterine devices avoided until hCG is normal
Persistent gestational trophoblastic disease or choriocarcinoma: methotrexate-based chemotherapy for low risk disease per FIGO scoring, or combination chemotherapy (commonly the EMA-CO regimen: etoposide, methotrexate, actinomycin D, cyclophosphamide, vincristine) for high risk disease

Referral: specialist gestational trophoblastic disease center for all confirmed molar pregnancies.

Miscarriage

Spontaneous pregnancy loss before 24 weeks gestation (definitions vary by country, some use 20 weeks), occurring in roughly 15 to 20% of clinically recognized pregnancies, the majority in the first trimester and the majority attributable to chromosomal abnormality.

Classified as threatened, inevitable, incomplete, complete, or missed (delayed, sometimes asymptomatic and identified incidentally on scan).

Transvaginal ultrasound is central: absence of cardiac activity with a crown-rump length of 7 mm or greater, or an empty gestational sac with a mean sac diameter of 25 mm or greater, confirms miscarriage per most current criteria (RCOG/ASRM); findings below these thresholds require a repeat scan in 7 to 14 days rather than immediate diagnosis, to avoid misclassifying a viable early pregnancy. In a pregnancy of unknown location, serial serum beta-hCG at 48 hours helps distinguish a viable pregnancy (expected rise of at least 53 to 66%) from a failing one.

Expectant management is first line for incomplete miscarriage, generally allowed up to 2 weeks, with a success rate around 80%; a urine pregnancy test at 3 weeks confirms completion
Medical management: misoprostol 800 mcg PV (per vaginum) as a single dose, repeated if needed; for missed miscarriage, pretreatment with mifepristone 200 mg PO 24 to 48 hours before misoprostol improves efficacy
Surgical management (manual vacuum aspiration or evacuation of retained products of conception under anesthesia): indicated for hemorrhage, infection, patient preference, or failed medical or expectant management
Anti-D prophylaxis for Rh negative women undergoing surgical management (regardless of gestation in many protocols), and for medical or expectant management beyond 12 weeks
Recurrent miscarriage (3 or more consecutive losses) warrants specialist workup: antiphospholipid antibody screen, parental karyotyping and/or products of conception karyotyping, pelvic ultrasound for uterine anomaly, and thrombophilia screening

Referral: early pregnancy unit for all suspected miscarriage; recurrent miscarriage clinic after 3 losses.

Molar Pregnancy

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management